Northeast Derm



NORTHEAST DERMATOLOGY MEDICAL HISTORY FORM NAME: __________________________________________________________ DATE OF BIRTH: _________________________________DRUG ALLERGIES NO KNOWN DRUG ALLERGIES I DO HAVE DRUG ALLERGIES, LISTED BELOW: LATEX NOVOCAINE EPINEPHRINE LIDOCAINE SULFUR PENICILLIN OTHER DRUG ALLERGIES: ____________________________________________________________________________CURRENT MEDICATIONS I DO NOT TAKE MEDICATIONS I DO TAKE MEDICATIONS, LISTED BELOW: ________________________________ 2. _____________________________ 3. ____________________________4. ________________________________ 5. _____________________________ 6. ____________________________(Feel free to submit a list of current medications that we may copy) ADDITIONAL MEDICAL INFORMATION YES NO DO YOU TAKE ANTIBIOTICS BEFORE YOUR TEETH ARE CLEANED? DO YOU TAKE ASPIRIN OR OTHER ANTI-INFLAMMATORY AGENTS DAILY? SKIN HISTORYHAVE YOU BEEN DIAGNOSED WITH MELANOMA? HAVE YOU BEEN DIAGNOSED WITH OTHER SKIN CANCERS? BASAL CELL CARCINOMA; SQUAMOUS CELL CARCINOMADO YOU HAVE PSORIASIS? DO YOU HAVE ECZEMA? PAST MEDICAL HISTORYASTHMA BLEEDING DISORDER CANCER DEPRESSION DIABETES HEART DISEASE HIGH BLOOD PRESSURE HIV KIDNEY DISEASE LIVER DISEASE OR HEPATITIS LUNG PROBLEM LUPUS, SCLERODERMA OR CONNECTIVE TISSUE DISEASE STROKE THYROID DISORDER OTHER, NOT LISTED ______________________________________________________________________________FAMILY HISTORY I DO NOT HAVE ANY HISTORY OF FAMILY MEDICAL CONDITIONS (skip to Social History) I have a family history of the following: MELANOMA PSORIASIS ECZEMA OTHER SKIN CANCERS CANCER AUTOIMMUNE DISORDERS SOCIAL HISTORY YES NO YES NO DO YOU DRINK ALCOHOL DAILY? DO YOU SMOKE? DO YOU DRINK OCCASIONALLY? DO YOU WORK WITH CHEMICALS? PLEASE LIST YOUR HEIGHT: ____________ WEIGHT: _____________WHICH PHARMACY DO YOU USE? NAME: __________________________ ADDRESS: __________________________ CITY: ____________________________ ................
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